loss, trauma, and human resilience · 13 adult resilience to loss and trauma • transient stress...

1

Loss, Trauma, and Human Resilience

George A. Bonanno, Ph.D.

TEACHERS COLLEGE

• obvious public health cost1. Focus on psychopathology

– chronic grief and depression (10%-15%)– Posttraumatic Stress Disorder (PTSD) (5%-10%)

2. Focus on impact of event: • Compare groups exposed vs. non-exposed• Compare average response across event

3. Mapping individual differences across events: some surprising findings

Bad things happen

7

PTE 1 year 2 years

Dis

rupt

ions

in n

orm

al fu

nctio

ning

mild

mod

erat

e

sev

ere

PTE

Psychopathology

1 year 2 years

Dis

rupt

ions

in n

orm

al fu

nctio

ning

mild

mod

erat

e

sev

ere

?

8

PTE 1 year 2 years

Dis

rupt

ions

in n

orm

al fu

nctio

ning

mild

mod

erat

e

sev

ere

Average response

Psychopathology

?

?

?

?

Bereavement literature:The absence of pronounced grief (“absent grief”) is rare and pathological ?

• denial or inhibition, generally maladaptive(Middleton et al., 1993)

• disordered mourning (Bowlby, 1980)

• personality pathology (Osterweis et al., 1984)

• cold and unfeeling (Bowlby, 1980, Rando, 1993) . . .• superficially attached (Horowtiz, 1990; Rando, 1988; Raphael,

1983)

9

Trauma literature:The absence of trauma is rare and occurs in exceptionally healthy individuals

• unexpected resilience (Tucker, Pfefferbaum et al., 2002).

• exceptional emotional strength (e.g., Casella, & Motta, 1990)

• Unusual courage (Druss & Douglas, 1988).

Resilience to loss and trauma1. The minimal response to a PTE is

neither exceptional nor pathological; it is resilience

2. Resilience is typically the most common outcome

3. There are multiple and sometimes unexpected pathways to resilience

Bonanno (2004, 2005). American PsychologistBonanno (2005) Current Directions in Psychological ScienceBonanno & Mancini (2008) Pediatrics

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PTE

Chronic

1 year 2 years

Dis

rupt

ions

in n

orm

al fu

nctio

ning

mild

mod

erat

e

sev

ere

Recovery

Delayed

Resilience

PTE

Chronic 5-30%

1 year 2 years

Dis

rupt

ions

in n

orm

al fu

nctio

ning

mild

mod

erat

e

sev

ere

Recovery 15-25%

Delayed 0-15%?

Resilience 35-60%

11

PTE

Chronic 5-30%

1 year 2 years

Dis

rupt

ions

in n

orm

al fu

nctio

ning

mild

mod

erat

e

sev

ere

Recovery 15-25%

Delayed 0-15%?

Resilience 35-60%

PTE

Chronic 5-30%

1 year 2 years

Dis

rupt

ions

in n

orm

al fu

nctio

ning

mild

mod

erat

e

sev

ere

Recovery 15-25%

Delayed 0-15%?

Resilience 35-60%

12

PTE

Chronic 5-30%

1 year 2 years

Dis

rupt

ions

in n

orm

al fu

nctio

ning

mild

mod

erat

e

sev

ere

Recovery 15-25%

Delayed 0-15%?

Resilience 35-60%

Resilience to Adversity

• Resilience in children (Garmezy, Rutter, Werner, Masten, Luthar, etc.)

• aversive and enduring life circumstances • protective factors foster positive outcomes at the end

point of the developmental period

• Resilience in adults • PTEs that are usually isolated events• … occurring in otherwise normal circumstances • protective factors foster minimal response or rapid

return to baseline

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Adult Resilience to Loss and Trauma

• Transient stress reaction (dis-equillibrium): brief period of fluctuations in levels of distress and well-being

• But . . . . . a relatively stable trajectory of healthy functioning (STHF)

• Capacity for generative experiences (new tasks, new relationships), positive emotions (Fredrickson et

al.) and laughter (Keltner & Bonanno, 1997)

The Changing Lives of Older Couples (CLOC) study

• 1,532 married individuals from Detroit area• 205 lost a spouse during the course of the

study, – interviewed prior to bereavement (on average 3

years pre-loss), – Interviewed at least twice after bereavement (6 and

18 months post-loss).

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-1

-0.5

0

0.5

1

1.5

2

2.5D

epre

ssio

n (C

ESD

)

Bonanno, Wortman, Lehman, Tweed, Haring, Sonnega, Carr & Neese (2002). Journal of Personality and Social Psychology

3 yrs pre-loss

6 mo. post-loss 18 mo. post-loss

Resilience

Depressed-Improved

Recovery

Chronic grief

Chronic depression9%17%

11%12%45%

-1

-0.5

0

0.5

1

1.5

2

2.5

Dep

ress

ion

(CE

SD)


3 yrs pre-loss


Resilience

Depressed-Improved

Recovery

Chronic grief


11%12%45%

15

Resilient individuals

• No evidence for delayed grief• Not unhealthy on any pre-loss measures

– normal quality marriage– Not rated as cold or social inept by interviewers

• Higher scores on pre-loss protective factors– Belief in just world– Acceptance of death– instrumental support

-1

-0.5

0

0.5

1

1.5

2

2.5

Dep

ress

ion

(CE

SD)


3 yrs pre-loss


Resilience

Depressed-Improved

Recovery

Chronic grief


11%12%45%

16

Depressed-improved Individuals

• Prior to the loss . . .• Ill spouse • Poorer quality marriages• More introspective and emotionally unstable• lowest levels of instrumental support, • believed that the world was particularly unjust

to them (“everyone gets the breaks but me”).

-1

-0.5

0

0.5

1

1.5

2

2.5

Dep

ress

ion

(CE

SD)


3 yrs pre-loss


Resilience

Depressed-Improved

Recovery

Chronic grief


11%12%45%

17

Resilient and depressed-improved evidence healthy adjustment during bereavement

• lowest in • grief symptoms (e.g., yearning),• processing of the loss, • searching for meaning, • avoidance/distraction,

• highest in • positive affect• Comfort from positive memories of deceased

Bonanno, Wortman & Nesse (2004). Psychology and Aging

Figure 1. Patterns of depression from pre- loss to 48- months post- loss (N = 92)

0

2

4

6

8

10

12

1 2 3 4Pre- loss 6-months post-loss 18- months post- loss 48- months post- loss

Chronic depression

Resilient

Chronic griefRecovery

Boerner, Wortman, & Bonanno (2005). Journal of Gerontology: Psychological Science

Depressed-improved

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Resilience to Trauma (violent or life-threatening events)

• Air war and emotional stress. Irving Janis (1951)– Hiroshima and Nagasaki

• Fear and courage. S. J. Rachman (1978)– WWII: British civilians during aerial bombardment

• Retrospective review of previously published studies• Not systematic• anecdotal• Studies not designed to measure resilient outcomes

High-exposure WTC sample: In or near the WTC on September 11th

• N = 75; longitudinal analyses n = 55 • Small but rare sample• Majority. . .

– were exposed to life-threatening danger– witnessed death/serious injury to others

Bonanno, Rennicke, & Dekel (2005) JPSP

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0

5

10

15

20

25

30

7 months 18 months

Pos

t-tra

umat

ic s

tress

Time since September 11

Resilient (35%)

Recovered (23%)

Delayed (13%)

Chronic (29%)

Clinical cut-off

0

5

10

15

20

25

30

7 months 18 months

Pos

t-tra

umat

ic s

tress


Resilient (35%)

Recovered (23%)

Delayed (13%)

Chronic (29%)

Clinical cut-off

20

0

5

10

15

20

25

30

7 months 18 months

Pos

t-tra

umat

ic s

tress


Resilient (35%)

Recovered (23%)

Delayed (13%)

Chronic (29%)

Clinical cut-off

0

5

10

15

20

25

7 months 18 months

Dep

ress

ion

(CE

SD

)


Resilient (35%)

Recovered (23%)

Delayed (13%)

Chronic (29%)

Normal mean

Clinical cut-off

21

0

5

10

15

20

25

7 months 18 months

Dep

ress

ion

(CE

SD

)


Resilient (35%)

Recovered (23%)

Delayed (13%)

Chronic (29%)

Normal mean

Clinical cut-off

0

5

10

15

20

25

7 months 18 months

Dep

ress

ion

(CE

SD

)


Resilient (35%)

Recovered (23%)

Delayed (13%)

Chronic (29%)

Normal mean

Clinical cut-off

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Friend-ratings of participant’s trajectory

Friend-ratings of participant’s trajectory

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Resilience and PTSD in NYC after 9/11

•Random digit dialing, probability sample of contiguous NYC area (N = 2752)

•Demographics comparable with 2000 census

•PTSD symptom estimates were high reliability when compared at 1, 4, and 6 months

•Cumulative PTSD at 6 months = 6.0%

Bonanno, Galea et al. (2006) Psychological Science

New York area 6 months after 9/11 (N = 2752)

14.5

11.8

21.4

26.1

31.3

11.2

25.4

12.3

6

0 10 20 30 40 50 60 70 80 90 100

involved in rescue + saw attack (3.3%)

involved in rescue (9.3%)

lost possession (2.3%)

injured (1.5%)

friend/relative killed + saw attack (3.1%)

friend/relative killed (15.4%)

in WTC (0.8%)

saw attack in person (19.0%)

overall (100%)

PTSD

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14.5

11.8

21.4

26.1

31.3

11.2

25.4

12.3

6

45.2

37

36

41

35.4

34.9

21.1

31.9

28.9

0 10 20 30 40 50 60 70 80 90 100




injured (1.5%)



in WTC (0.8%)


overall (100%)

PTSD 2 or more symptomsBonanno, Galea et al. (2006)


14.5

11.8

21.4

26.1

31.3

11.2

25.4

12.3

6

45.2

37

36

41

35.4

34.9

21.1

31.9

28.9

40.3

51.2

42.6

32.8

33.4

53.9

53.5

55.6

65.1

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%




injured (1.5%)



in WTC (0.8%)


overall (100%)

PTSD 2 or more symptoms 1 or 0 symptom

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Additional validity data

0

20

40

resilient PTSD0

102030

resilient PTSD

40

50

60

resilient PTSD0

5

10

resilient PTSD

Depression Cigarette use

Alcohol use Marijuana use

Bonanno, Galea et al. (2007)

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Treatment for Breast Cancer• 84 women treated for breast cancer• Assessed depression after radiation treatment

and 3 and 6 months post-treatment• 51 (61%) had very low levels of depression

throughout the study• “Our results support assertions . . . that

resilience is the most common response to loss or trauma, specifically here the experience of breast cancer”

Deshields et al. Psycho-oncology (2006)

Severe Acute Respiratory Syndrome (SARS)

• Fall, 2002: reported in Guangdong Province, People’s Republic of China

• Spring 2003: spread to over 30 countries, over 8000 people infected

• Hong Kong hit hard: 1755 infected, 299 dead• Origins and treatment poorly understood• Fear of death, quarantine, abandonment• Study of 997 hospitalized survivors

Bonanno, Ho et al. (2008) Health Psychology

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SARS6 12 18

Nor

mal

rang

e of

func

tioni

ng

mean

SD

Months since hospitalization

SARS 12 months 18 months

SF-1

2 M

CS

norm

s fo

r Hon

g K

ong

48.4

39.6

6 months

Average response across time

(mean)

average

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SF-1

2 M

CS

norm

s fo

r Hon

g K

ong

48.4

39.6

Resilience 35%-55%

Recovery 10%-5%

Delayed 0%-15%

6 months

Chronic 10%-30%

Prototypical (anticipated) trajectories


SF-1

2 M

CS

norm

s fo

r Hon

g K

ong

48.4

39.6

Resilience 36%

Recovery 10%

Delayed 13%

6 months

Chronic 42%

Observed (latent class mixture models) trajectories

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SF-1

2 M

CS

norm

s fo

r Hon

g K

ong

48.4

39.6

Resilience 36%

Recovery 10%

Delayed 13%

6 months

Chronic 42%



SF-1

2 M

CS

norm

s fo

r Hon

g K

ong

48.4

39.6

Resilience 36%

Recovery 10%

Delayed 13%

6 months

Chronic 42%


30


SF-1

2 M

CS

norm

s fo

r Hon

g K

ong

48.4

39.6

Resilience 36%

Recovery 10%

Delayed 13%

6 months

Chronic 42%


average

Clark et al. (2008)Clark, Diener et al. (2008)The Economic Journal

31

Clark et al. (2008)Clark, Diener et al. (2008)The Economic Journal

Clark et al. (2008)Clark, Diener et al. (2008)

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Clark et al. (2008)Mancini, Bonanno, & Clark (in prep)

bereavementWidowhood (latent class mixture model)

58.5%

21.0%

Years before and after loss

4.4%15.9%

Clark et al. (2008)

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Divorce (latent class mixture model)

Years before and after divorceMancini, Bonanno, & Clark (in prep)

9.1%71.8%

19.1%

Clark et al. (2008)Clark, Diener et al. (2008)

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Marriage (latent class mixture model)

Years before and after marriageMancini, Bonanno, & Clark (in prep)

5.2%6.9%

6.1%

79.8%

Why are some adults resilient?

3. There are multiple and sometimes unexpected pathways to resilience

• resilience is a heterogeneous category• no single way to be resilient

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Multiple, Unique Predictors of resilient outcomes• Demographic factors (gender, age)• Fewer past and current stressors• Pre-event beliefs (e.g., acceptance of death, justice)• Reduced search for meaning• Reduced worry/rummination• Capacity for positive emotion• Social resources (support, broad network)• Economic resources (employment, no loss of income)• Health resources (good health, absence of disease)• Genetic disposition (G X E – 5HTT)• Personality

– Pragmatic coping– Flexibility

Resilience to loss and trauma1. Minimal response to a PTE is resilience

2. Resilience is common• 41% -53% (Bonanno et al., 1995 1999)• 45% -56% (Bonanno et al., 2002)• 50% -52% (Bonanno, Moskowitz et al., 2005)• 35% (Bonanno, Rennicke et al., 2005)• 61% (Deshields et al., 2006)• 36% (Bonanno, Ho et al., 2007)• 33% - 56% (Bonanno, Galea et al., 2006)

3. There are multiple and sometimes unexpected pathways to resilience• Exposure, genes, social support, resources, demographics• Personality / coping habits, reduced search for meaning

• Pragmatic coping• flexible adaptation (most resilient people)

resiliencerecovery

chronic -Transient variability (stress)-Stable trajectory of functioning-Positive emotion, flexiblity

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Laughter and smiling

What’s so funny about loss and trauma?

Bonanno, & Keltner (1997). Journal of Abnormal PsychologyKeltner & Bonanno (1997). Journal of Personality and Social Psychology

Laughter and Bereavement• laughter as dissociation (breather)

– helps undo negative emotion (Fredrickson)– associated with distancing, reinterpreting, or

reframing of negative events (akin to humor)• Social benefits of laughter

– laughter is pro-social, increases group cohesion– laughter is contagious and evokes positive

responses in others

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Duchenne expressions

orbicularis oculi

38

Intentional non-Duchenne smile

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Spontaneous Duchenne smile Intentional non-Duchenne smile

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Intentional non-Duchenne smile

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Intentional non-Duchenne smile Spontaneous Duchenne smile

Duchenne and nonDuchenne smiles

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Positive Emotional Expression• the orbicularis oculi muscles (surround the eye)

contract involuntarily during positive emotional responding

• Duchenne and non-Duchenne expressions appear to be associated with different neural pathways

• nonDuchenne expressions are associated with social politeness; also concealment, deception

• Only “Duchenne” expressions are associated with genuine positive emotion, contagion

Are Positive Expressions Functional During Bereavement?

• Proportion of participants showing facial expressions in early months of bereavement

• Duchenne smile 60% Duchenne laugh 55%• anger 60% Contempt 32%• Disgust 32% Fear 16%• Sadness 32%

Bonanno, & Keltner (1997). Journal of Abnormal Psychology, 106, 126-137.

Duchenne expressions predicted better long-term adjustment

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Keltner & Bonanno (1997) JPSP

Duchenne expressions evoke positive response in untrained observers

Smiling in the face of adversity:An experimental study

• NYC college students beginning college just before the September 11th terrorist attack.

9/11

W1 distress

20032001 2002

W2 distress

Experimental task

Papa & Bonanno, 2007, Emotion

Sad

Amusing

“Talk about Your life

since 9/11”

film

or

5 minuteMonologue

44

results

• Main effect– Duchenne smiles predicted reduced distress

at W2 (controlling for W1 distress)• Interaction effect

– Smile X film context• Mediating effects

– Double mediated moderation

0.4

0.6

0.8

1

Hi Duchenne Smiles Low Duchenne Smiles

Amusing Film

Sad Film

Duchenne smiling after a sad film predicted less long-term distress

Papa & Bonanno, 2007, Emotion

T2 d

istre

ss

45

Undoing Mediates

Duchenne smilesin sad condition

T2 distress

Reduction of negativeaffect during monologue

+

Social Network Size Mediates

Duchenne smilesin sad condition

T2 distress

Social network size+

46

Why do we have emotions?• Emotions are functional (Ekman, 1992, 1993; Frijda, 1986;

Lazarus, 1991; Tooby & Cosmides, 1990).• The experience of affect

– Clarifies the kind of response that may be needed– motivates

• The expression of emotion– communicates information – influences and regulates the behavior of others

• Physiological systems are recruited– prepares us to respond

• Negative and positive emotions

Emotion and Adversity• Traditional theories emphasized unrestricted expression

of negative emotions– The work of mourning (Freud, 1917)

– psychological debriefing (Everly & Mitchell, 1999)

• Greater expression of negative emotion is often predictive of poor long-term functioning (Bonanno & Keltner, 1997; Seery et al., 2007)

• Emotions are useful but also efficient; ephemeral, serve their adaptive functions quickly (Bonanno, Goorin, & Coifman (2008)

• When prolonged, emotions are maladaptive (e.g., prolonged sadness leads to withdrawal, undermines support)

• positive emotions help to regulate (undo) negative states, bolster social support

• Oscillation (Schut & Stroebe 1999; Bisconti et al., 2004; 2006)

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EmotionalWell-Being

Occasion of Measurement

c

b

aFigure 1.

d

Bisconti, Bergeman, & Boker (2006)

Stress reactivity: a pendulum with friction

35

50

65

80

95

110

125

140

155

1 5 9 13 17 21 25 29 33 37 41 45 49 53 57 61 65 69 73 77 81 85 89 93 97

Day


Wel

l -be

ing

Average fluctuations in well-being following the death of a spouse

resilient

chronic

48

35

50

65

80

95

110

125

140

155

1 5 9 13 17 21 25 29 33 37 41 45 49 53 57 61 65 69 73 77 81 85 89 93 97

Day


Wel

l -be

ing

Daily fluctuations in well-being following the death of a spouse

resilient

chronic

Adaptive flexibility

• beliefs that foster flexibility in coping – Believe they can influence the outcome of events– View (reframe) stressful life events as challenges

• Capacity for positive emotion helps regulate distress, fosters social support from others

• Flexible repertoire of coping and emotion regulation behaviors

Most resilient individuals are generally healthy people

•Ego-resiliency (Block & Block, 1980)

•Hardiness (Bartone, 1999; Kobasa, 1979)

•Secure attachment style (Fraley & Shaver, 1998; Fraley, Fazzari, Bonanno, & Dekel, 2006; Mikulincer & Shaver, 2004)

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Expressive Flexibility

• flexible application of coping strategies in a manner that corresponds with the nature of the stressor (Cheng, 2001).

• “whether one expresses or suppresses emotional expression is not as important for adjustment as is the ability to flexibly express or suppress as demanded by the situational context” (Bonanno et al., 2004, Psychological Science)

• Expressive flexibility is trait-like (Seivert & Bonanno, 2008)

Thank you

50

Expressive Flexibility Task

• View emotion-evoking photos– rate own affect

• Observed by another participant (on monitor)– Will “try to guess your emotion”

• Three within-subjects conditions– Enhancement of expression– Suppression of expression– Control – monitor turned off

Bonanno, Papa, Lalande, Westphal,& Coifman (2004) Psychological Science

1

2

3

4

5

6

7

Enhancement Suppression control

Subjective Emotion(self-report)

ExpressedEmotion(observer ratings)

Expressive regulation condition

Affe

ct ra

tings

Expressive enhancement abilityExpression – no monitor (control)

Suppression abilityNo monitor (control) -- suppression

51

Expressive flexibility (EF) and adjustment

• NYC college students who had begun college just days before the September 11th

terrorist attack.

9/11

W1 distress

20032001 2002

W2 distress

EF task

Bonanno, Papa, Lalande, Westphal,& Coifman (2004) Psychological Science

-.27*Flexibility (enhancement + suppression)

-.03filler problems completed

F(3,80)=5.73***.18.26*T1 distress

ModelR2BetaDV = W2 distress

-.23*Expression suppression ability

-.24*Expressive enhancement ability

-.03filler problems completed (cognitive resources)

F(4,80)=4.24**.19.26*W1 distress

ModelR2BetaDV = W2 distress

52

Replication and extension

• Repeating same task in same participants3 years later (n = 101)

• A stable ability: Test-retest = .62• Enhanced expression and suppression each

predict anonymous friend ratings of participants’ adjustment

• flexibility moderated the relationship of acute life events and adjustment

Seivert & Bonanno (2008)

Flexibility in the expression of positive emotion

• Every adaptation has its cost– e.g. the peacock’s tail

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Are positive emotions always adaptive?

• Every adaptation has its cost– E.g. peacock’s tail

• Fosters sexual selection (adaptive)• Makes susceptible to predation (maladaptive)

• Duchenne laughter and smiling – Foster social affiliation (adaptive)– But ??. . . .(maladaptive?)– . . . Are there situations in which these signals

are confusing or inappropriate?

4

5

6

7

8

9

10

low T1 Duchenne smile high T1 Duchenne smile

CSA disclosureCSA nondisclosure

T2 S

ocia

l with

draw

al

nonabused

Bonanno, Colek et al. (2007) Emotion

Context matters:Positive expressions are not always adaptive

55

Context matters:Positive expressions are not always adaptive

Bonanno, Colek et al. (2007) Emotion

loss, trauma, and human resilience · 13 adult resilience to loss and trauma • transient stress...

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